There have been overtures towards establishing a residency program in pain medicine for the past several years through the American Board of Pain Medicine that has actually developed a curriculum for the process. However, the ABA staunchly opposes any incursion into the dilution of their fellowship positions through establishment of a pain residency. Because most who teach in academics have never practiced outside of academics, there develops a culture of insular self-rightousness among attendings utilizing the reasoning that "what we teach is all that is important in pain medicine. ". Most attendings in academia have never attended an ISIS course, an ASIPP course, or a PASSOR course, since it is assumed they have sufficient knowledge in the field and need no further training. Of course pain medicine is not a stoic field with few changes occuring slowly over time as is anesthesiology, therefore a year without attending conferences on advances in pain medicine can leave one quite far behind.
Based on national survey results of a survey of pain fellows I conducted in 2004, there is a significant deficit in knowledge in many areas on the month of finished the pain fellowships. These included deficits in posture/gait/muscular function analysis, practice finance and practice operation, outpatient functional restoration, chronic return patient mangagement, xray interpretation, and MRI interpretation.
The ABMS has specific requirements for board certification, one of which is the demonstration of a distinct branch of medicine from other branches and the presence of a residency program. Therefore ABMS board certification in pain medicine (not the "additional qualifications certification") would require the development of a residency program first. The residency program cannot be developed without the blessing of the directors of residency programs from other residencies (eg. anesthesiology, PM&R, etc). Emergency medicine required 8 years to develop their residency program and that was with significant input from a variety of other specialties defining what they could and could not do in their sphere of practice. These guidelines were called "clinical pathways" and were developed by other specialists to prevent emergency physicians from straying too far from treating emergencies and insuring the specialists would not be cut out of the loop of patient treatment. With pain medicine, no such pathways are possible due to the American Society of Anesthesiology and American Board of Anesthesiology positions that a one year training program is enough to supply a physician with all he will need for clinical practice. Unlike other subspecialties as vascular surgery being a fellowship of surgery, pulmonology is a branch of internal medicine, etc, pain medicine is a branch of many specialties that are of competing and opposing viewpoints on the treatment of pain. Pain medicine is related to anesthesiology, but is more related to PM&R and neurology if you discount the "block jocks" who run mills without ever making a diagnosis (effectively continuing on in the course defined by anesthesiology) and do not want any long term relationships with patients (also consistent with the anesthesia model of the briefest possible encounters). The success of anesthesia in batting nearly 1000 all the time cannot be transferred to pain medicine in which there are many possible diagnoses that require significant numbers of recurrent visits to diagnose and treat, and even under the best of situations batting 500 is an excellent outcome for pain medicine. Anesthesiologists continue to think along the lines of standing at the plate batting one after another out of the park, never having to run the bases. We run bases in pain medicine. We strike out. We hit a lot of foul balls. Anesthesiologists do not, and therefore the simplistic transfer of patient care models from OR anesthesia to pain medicine is a setup for failure and frustration. Certainly one cannot make such a radical transformation in thinking and approach after one year of training, but this is exactly what is demanded by pain fellowship programs.
We have not yet reached the threshhold of frustration by those who matriculate from fellowship programs that encourge continued thinking like an anesthesiologist, largely because the insurance carriers are still paying their $400 for a 4 minute epidural block without requiring any standards or criteria be met. The block jocks therefore continue to stick needles in up to 50 patients a day without applying any ethics or medical science to what they are doing, since they know no better. This is what the fellowship programs have produced and what the insurance companies (so far) continue to foster. It won't last forever. At that point when the insurance industry clamps down on the overperformance of endless blocks without medical justification, hopefully we will see these block jocks make the transition back into OR anesthesia where they belong. Then perhaps we will develop a comprehensive pain medicine residency that teaches all facets of pain medicine.
